Radiation Therapy Nursing
in GCC Hospitals

• Skin reaction: Most common acute toxicity; erythema (Grade 1) → dry desquamation (Grade 2) → moist desquamation (Grade 3) in skin folds; Grade 4 = ulceration (rare)
• Fatigue: Universal; peaks in final weeks; discuss energy conservation, gentle exercise (evidence-based)
• Lymphoedema: Risk after axillary RT ± axillary dissection; nurse education on precautions (no BP in affected arm, avoid cuts, skin hygiene)
• Pneumonitis: Risk 4–12 weeks post-RT if lung volume irradiated; monitor for cough, dyspnoea, fever; CXR/CT if suspected
• Cardiac late effects: Left-sided breast RT — deep inspiration breath-hold (DIBH) technique reduces cardiac dose; nurse explains technique
• Body image: Psychological support; assess emotional wellbeing; refer breast care nurse/psychologist

• Radiation pneumonitis: Onset 4–12 weeks post-RT; symptoms: cough, progressive dyspnoea, fever, pleuritic chest pain; Grade ≥2 requires oral prednisolone (40–60 mg tapered over 6 weeks)
• Oesophagitis: Onset week 2–3 during RT; dysphagia, odynophagia; soft diet, liquid analgesics, mucaine/viscous lignocaine; Grade 3 may need NGT/PEG
• Fatigue: Often compounded by underlying disease and systemic treatment
• Skin reaction: Usually mild for lung RT — monitor entry/exit beam sites
• Haemoptysis: May be tumour-related or RT reaction — assess quantity; escalate if significant
• Pulmonary fibrosis: Late effect at 6–24 months; progressive breathlessness; refer respiratory team

• Radiation proctitis (acute): Diarrhoea, urgency, tenesmus, rectal bleeding; onset week 3–4; low-residue diet, loperamide, antispasmodics, rectal steroid foam
• Radiation cystitis (acute): Dysuria, frequency, urgency, haematuria; hydration ↑ 2–3L/day; alpha-blocker (tamsulosin), exclude UTI
• Vaginal effects: Vaginal dryness, stenosis (cervix/endometrial RT) — vaginal dilators START 4–6 weeks post-RT; water-based lubricants; sensitive patient education
• Sexual dysfunction: Erectile dysfunction (prostate RT), dyspareunia, libido — counsel patient and partner; referral to sexual health if needed
• Lymphoedema: Post-pelvic RT + node dissection — bilateral leg/genital lymphoedema; compression, skin care
• Late effects: Fistula (rare), bowel stricture, rectal bleeding (chronic proctitis); refer GI/urology as appropriate

• Fatigue: Most common; profound during and after WBRT (whole brain RT); counsel on activity pacing
• Alopecia: Within the radiation field only (not universal as with chemotherapy); partial or complete depending on field; may be permanent with high dose
• Nausea/vomiting: Especially WBRT; prescribe prophylactic antiemetic (dexamethasone reduces cerebral oedema and nausea)
• Somnolence syndrome: Onset 6–8 weeks post-RT; extreme sleepiness, lethargy, low-grade fever; self-limiting (2–4 weeks); reassure patient and family
• Cognitive effects: Concentration, memory — more marked with WBRT vs. SRS/focal RT; memantine considered in WBRT
• Radiation necrosis: Late effect months–years post-RT; focal neurological deficits; MRI vs PET to distinguish from tumour recurrence; bevacizumab if severe

• Gentle washing: Mild, unscented soap (Dove unscented); lukewarm water; gentle pat dry with soft cloth — do NOT rub
• Moisturisers: Apply aqueous cream, Calendula cream, or prescribed barrier cream twice daily; apply AWAY from field markings
• Clothing: Loose-fitting, soft cotton clothing over treated area; avoid underwired bras during breast RT
• Shaving: Electric razor only within treatment field if necessary; ideally avoid shaving treated skin
• Deodorant: Aluminium-free deodorant for axilla/breast treatments; some centres advise none in field during RT
• Heat: No hot water bottles, heat pads, or saunas over treated area

• Swimming pools: Chlorinated water irritates irradiated skin — avoid during RT course and until healed
• Jacuzzi/spa: Heat, chemicals, and jets — contraindicated during RT
• Sun exposure: Irradiated skin remains hypersensitive to UV for at least 1 year post-RT — SPF 50+ sunscreen, protective clothing
• Perfumes/fragrances: Alcohol-based products can dry and irritate treated skin
• Tape: Medical tape directly on irradiated skin can cause trauma on removal
• Scratching: Counsel patient to pat rather than scratch pruritic areas; antihistamine if severe itch

• Permanent tattoos: Small (1–2 mm) ink dots made at simulation — permanent; patient MUST NOT attempt to remove; explain purpose
• Temporary ink marks: Some departments use temporary skin markers for setup; patient must not wash these off; report if marks become faint
• Why markers matter: Ensure identical patient positioning each fraction — treatment accuracy depends on reproducible alignment
• Faded marks: Instruct patient to inform RTT immediately if marks fade — do NOT redraw without RTT confirmation
• Cultural sensitivity: Some GCC patients may have concerns about permanent tattoos (Islamic perspective); discuss with clinical team — alternative methods available in some centres

• What is bolus? Tissue-equivalent material (wax, aquaplast) placed on skin surface before each fraction
• Purpose: Deliberately increases skin dose — used when tumour is superficial (post-mastectomy chest wall, skin tumours, scalp)
• Effect on skin: Significantly increases skin reaction severity — anticipate and manage more aggressively
• Nurse role: Be aware when bolus is part of the plan; explain to patient why skin reaction will be more significant; increase frequency of skin assessment
• RTT applies bolus: Nurses do not apply bolus — this is an RTT function during treatment delivery

• Source: Iridium-192 (Ir-192); high activity source on a cable in remote afterloading machine
• Remote afterloading: Source travels from machine through tubes/catheters to patient; ALL staff leave room during treatment (minutes only)
• Between fractions: Source is back in the machine — patient has NO radioactive material; nurse can provide full care without any special precautions
• Typical sites: Cervix, vagina, endometrium, prostate, breast, skin, lung, oesophagus
• Duration per fraction: Minutes (typically 10–20 minutes of actual beam-on time)
• Nursing care: Pain management (applicators can be uncomfortable), catheter care, anxiety support, IV access, vital signs

• Sources: Caesium-137 (Cs-137) wires/pellets; or Iodine-125 (I-125) seeds (permanent prostate implants)
• Patient IS radioactive: Sources remain in or near patient for extended period (hours to days) or permanently (seeds)
• Radiation protection principles — Time, Distance, Shielding:
• Time: Minimise time spent close to patient; prioritise care tasks; prepare everything before entering room
• Distance: Inverse square law — doubling distance reduces dose to quarter; stand at foot of bed where possible; lead shield at bedside
• Shielding: Lead apron/shield between nurse and source; portable lead screens at bedside

• Procedure: Transrectal ultrasound-guided implant of 60–120 I-125 seeds into prostate; day-case or overnight procedure
• Patient goes home radioactive: Seeds emit low-energy radiation; activity decays over ~1 year (half-life 60 days)
• Patient discharge education (critical):
• Avoid prolonged close contact with pregnant women for first 2 months
• Keep children (under 10) at arm's length for extended periods for first 2 months
• Can sleep in same bed as adult partner after the first few weeks
• Urinary symptoms (frequency, urgency, hesitancy) common first few weeks — alpha-blocker medication
• Seed loss: Small risk of passing seed in urine — instruct to urinate through strainer for first 2 weeks; provide sharps container for seed disposal

Cervical and endometrial cancers — most common brachytherapy site requiring inpatient nursing care.

• Types: Intracavitary (ring and tandem, ovoids) for cervical cancer; vaginal cylinder for endometrial
• HDR procedure nursing: Patient in theatre for applicator insertion under GA/sedation; post-procedure vital signs, pain assessment, catheter care, urinary monitoring
• LDR inpatient stay: Caesium sources in situ 20–40+ hours; bed rest with catheter; full radiation precautions; bowel preparation to prevent displacement
• Pain management: Applicators can cause significant pelvic pain — regular analgesia, reassess frequently
• Vaginal packing: Gauze packing maintains applicator position; nurse checks packing has not displaced; report any bleeding
• Post-procedure: Applicator removal (often in ward by medical team); vaginal bleeding/discharge expected; discharge care and vaginal dilator education
• Cultural sensitivity: Pelvic examinations and vaginal procedures — ensure privacy, same-gender staff where possible, clear explanation

• Use: Head & neck squamous cell carcinoma — alternative to cisplatin (bioradiotherapy)
• Acneiform rash: Characteristic pustular rash on face, scalp, chest, back; grade 1–4; paradoxically associated with better tumour response; moisturise, topical/systemic antibiotics (doxycycline) if Grade ≥2
• Infusion reactions: Risk at first infusion — premedicate with antihistamine + corticosteroid; observe during infusion; Grade 3–4 = stop infusion immediately, manage anaphylaxis protocol
• Combined skin toxicity: Cetuximab rash + radiation dermatitis in same fields — complex skin management required
• Electrolytes: Hypomagnesaemia common — monitor and replace

• Abscopal effect: RT may enhance systemic immune response to immunotherapy — irradiated tumour acts as in-situ vaccine; being studied in clinical trials
• Agents used: PD-1/PD-L1 inhibitors (pembrolizumab, nivolumab, durvalumab) with RT in lung, H&N, bladder, oesophageal cancers
• Immune-related adverse events (irAEs): Pneumonitis, colitis, hepatitis, thyroiditis, dermatitis, myocarditis — can occur during or after RT; may be difficult to distinguish from radiation toxicity (pneumonitis)
• Pneumonitis differential: Radiation pneumonitis vs immunotherapy pneumonitis vs combined — clinical/radiological assessment; treatment = steroids in both cases but inform oncologist immediately
• Nurse education: Educate patients about immune toxicity symptoms — breathlessness, diarrhoea, rash, jaundice; when to call urgently

• Androgen deprivation therapy (ADT): LHRH agonists (goserelin, leuprolide) ± anti-androgens given before, during, and after RT for intermediate/high-risk prostate cancer
• Duration: Short-term (6 months) for intermediate-risk; long-term (2–3 years) for high-risk; combined with RT shown to improve survival
• Nurse role — ADT side effects:
• Hot flushes: Common and distressing; lifestyle advice (cool environment, layers), venlafaxine, cyproterone for refractory cases
• Bone health: ADT reduces bone density — baseline DEXA scan, calcium/vitamin D supplements, bisphosphonates if indicated; fracture risk assessment
• Mood/cognitive effects: Depression, memory changes, fatigue — psychological screening, refer if needed
• Metabolic syndrome: Weight gain, glucose intolerance — lifestyle advice, monitor blood sugar
• Sexual function: Erectile dysfunction, loss of libido — counsel patient and partner; referral if needed

Steroids are frequently used in radiation oncology for acute toxicity management.

• Dexamethasone — brain RT: Reduces cerebral oedema; 4–16 mg/day during brain RT or for raised ICP; taper after RT; monitor blood glucose (steroid-induced hyperglycaemia common)
• Prednisolone — radiation pneumonitis: Grade ≥2 pneumonitis; 40–60 mg/day tapered over 6–12 weeks; DO NOT stop abruptly
• Nurse monitoring on steroids: Blood glucose (daily initially), mood changes (insomnia, euphoria, psychosis), GI symptoms (prescribe PPI), blood pressure, infection risk, Cushingoid features
• PCP prophylaxis: Cotrimoxazole for patients on prolonged high-dose steroids (risk of Pneumocystis pneumonia)
• Steroid card: Ensure patients on prolonged steroids carry a steroid card; do not stop without medical instruction

• Colorectal cancer: Incidence rising significantly across GCC; Saudi Arabia among top regional rates; linked to dietary changes and decreased physical activity
• Breast cancer: Most common cancer in GCC women; younger age at presentation vs. Western populations (often 40s–50s); increasing screening awareness
• Thyroid cancer: Disproportionately high rates in Gulf region — particularly UAE; reasons under investigation
• Head & neck: Oral cancers linked to smokeless tobacco (shamma, nass) in GCC male populations
• National registries: UAE Cancer Registry (MOH); Saudi National Cancer Registry (MOH) — tracking trends and driving policy
• Proton therapy expansion: Multiple GCC countries investing in proton centres; specialist nursing roles growing

• Family-centred disclosure: Diagnosis may be shared with family before or instead of patient in some cases; respect family wishes while balancing patient autonomy; navigate sensitively with MDT guidance
• Ramadan: Some patients wish to continue RT during Ramadan; discuss treatment timing with team; oral medications (antiemetics, analgesics) may be taken with Suhoor/Iftar; hydration strategies if receiving concurrent cisplatin
• Halal medications: Confirm halal status of medications if patient requests; gelatine-containing capsules — alternatives available; liaise with pharmacy
• Permanent tattoos: RT setup tattoos may be concerning for some Muslim patients; discuss with clinical team — some centres offer removable ink marks or sticker dots as alternatives (though less reproducible)
• Modesty: Breast and pelvic RT requires exposure — ensure privacy, same-gender staff where possible, explain all procedures, allow family chaperone if appropriate
• End-of-life discussions: Palliative RT discussions — involve family, consider chaplaincy/Islamic spiritual support, respect beliefs around life-prolonging treatment

• Radiation Oncology Nurse (staff): Assessment, education, toxicity management; based in RT department or outpatient clinic
• Oncology CNS (Clinical Nurse Specialist): Advanced practice; speciality-specific (H&N, gynaecological, prostate CNS); leads nurse-led clinics, complex case management
• Research Nurse / Clinical Trials Coordinator: RT departments run multiple clinical trials; research nurses manage trial patients, data collection, regulatory compliance
• Oncology Nurse Educator: Staff education, patient education programmes, policy development
• Brachytherapy Nurse Specialist: Dedicated role in high-volume brachytherapy centres; procedure support, patient management, radiation safety expertise